Recently, old arguments about the appropriate role of the hospital emergency room (ER) in our health care system have resurfaced as the nation considers its next President. Given the high profile of the issue and the wide array of public opinions on the matter, now’s a good time to unpack the arguments by investigating what federal protections patients have in the ER, the policy questions this issue raises, and—spoiler alert!—why we think the ER makes a better backstop than it does a coverage program.

While it’s certainly true that the ER has become the default option for many people to receive health services, equating ER usage to comprehensive health coverage ignores routine pitfalls patients face when attempting to get care in the ER. The mantra that “anyone can get free care in the ER” is easy to dish out when one is a card-carrying member of the insured class, but—as we point out below—it’s full of misconceptions.

Misconception #1: ERs Have to Treat All Comers, All the Time The Emergency Medical Treatment and Labor Act (EMTALA), passed in 1985, requires hospitals to provide emergency care to all patients regardless of ability to pay. This qualification is key. While it provides certain protections to patients with emergency medical conditions or in active labor, “emergency” care isn’t synonymous with “medically necessary” care. Simply put, hospitals are not required to treat non-emergencies.

For example, The New York Times reported health care giant HCA has implemented a policy of turning away patients with “minor illnesses like the flu” to cut down on costs. The trouble with this approach is that one patient’s “minor illness” might be the next public health crisis; and, it assumes that the patient in question has somewhere else to go for care. And, “minor” issues aren’t always so minor. In another chilling excerpt, “[o]ne doctor, who…still works as an emergency physician, recalled one episode in which he was told to turn away a young boy with a deep cut in his arm because it was not bleeding profusely and he therefore did not meet the criteria.” Stitches, chemotherapy, diabetes and asthma treatments, preventive screenings – many forms of care may be medically necessary but still outside the EMTALA definition of an emergency, depending on the circumstances.

Misconception #2: If You Can’t Pay, You Won’t Be Asked To While EMTALA requires hospitals to treat patients regardless of ability to pay, it doesn’t prevent hospitals from sending bills; require them to offer any help to patients who may be low-income, uninsured or underinsured or direct them to public programs like Medicaid; or limit the steps they take to collect on outstanding debts. Nothing in EMTALA requires hospitals to provide free care. In fact, patients who are treated in the ER often go home with big bills that have lasting, sometimes devastating, effects on their family’s financial stability. Many studies show a link between medical debt and foreclosure, poor credit ratings and bankruptcy.

Misconception #3: Hospitals Are an Ideal Place to Get Health Care Claiming that people can rely on the ER as a “provider of first resort” sidesteps the real limitations that come with the territory. First, ER patients don’t always have access to ongoing primary, specialty or preventive services, or to coordinated care they would receive in a primary care setting that would help them avoid acute episodes from chronic illnesses like asthma and ear infections. These and other chronic episodes need ongoing attention and can be better managed through good primary care (the Affordable Care Act [ACA] has a provision for that – see more on medical homes). Second, inappropriate use of the ER contributes to overcrowding, which can lead to deadly delays in care (see this New England Journal of Medicine piece in which a doctor reflects on losing his mother to stroke as she waited for a bed in an overcrowded ER).

Closing the Holes in the Hospital Safety Net The hospital ER has its role in our health care system, but it is no substitute for comprehensive health care and coverage. It often fails to offer cost-effective, comprehensive care. But until everyone has affordable coverage and meaningful access to quality care, millions will continue to lean on hospital ERs for care. That’s why Community Catalyst and dozens of other consumer advocates recently weighed in on another ACA provision that helps patients address the financial toll hospital bills can take.

This summer, the IRS issued proposed rules that further define how hospitals should treat patients, in the ER or otherwise, who can’t afford to pay the bill. Recall that earlier this spring it was widely reported that a non-profit hospital in Minnesota was using a third-party billing agent that embedded agents in ER waiting rooms. These agents allegedly pressured patients to pay before seeing a doctor. Taking a no-nonsense approach in rulemaking, the IRS proposed rules would ban hospitals and third-party contractors from demanding payment in areas where emergency care is provided and hold hospitals responsible for most actions performed by third-party billing and collection contractors. (For a more detailed summary of the proposed rules, go here.)

These rules won’t address all of the problems that arise from our system’s over-reliance on ER care. But, they are an important step to protecting patients who have to rely on the hospital safety net. These resources help explain how the IRS proposed regulations will help cushion the landing.

– Jessica Curtis, Hospital Accountability Project Director & Eva Marie Stahl, Policy Analyst